Top Provider Questions – Medical Review
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- We have been having difficulties with acknowledgment of our electronic signature during the Medical Review process. This has caused denials. Is there a specific expectation?
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Medicare Program Integrity Manual (Pub. 100-08), Ch. 3, §3.3.2.4 requires signatures to be legible and authenticated. The MLN Matters® Special Edition article, SE1419 is available as a reference to educational resource related to signature requirements for Medicare-covered services. Refer to the CGS "Signature Guidelines for Medical Review" quick resource tool for situations where Medical Review will re-ADR the claim. When reviewing the claim, Page 08 will show the reason code "5ADR2", which explains that additional documentation for the signatures is needed. In addition, a detailed explanation of the documentation required will appear on FISS Page 04 (REMARKS). The additional documentation must be submitted within 20 calendar days of the request. If the documentation is not received by day 20, the claim will be denied.
Reviewed 09/30/2021
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- Can you review signature requirements on the certificate of terminal illness for hospice?
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Signature requirements for the certification of terminal illness can be found in the Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 9, §20.1 and the Medicare Program Integrity Manual (CMS Pub. 100-08) Ch. 3 §3.3.2.4. In addition, as you develop your own Hospice election statements and certifications of terminal illness, please review the MLN Matters Special Edition Article SE1628 for specific requirements you must include for valid documentation as well as example text.
Reviewed 09/30/2021
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- Are the ADR first level reviews always reviewed by nurses?
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Yes, all CGS Medical Review staff that review ADRs are Registered Nurses.
Reviewed 09/30/2021
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- I just received my FISS access, and I found that I have a couple of hospice claims that went to ADR. They were denied due to the time limit. How do I go about resubmitting these?
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If you have claims that were denied with reason code 56900 (no response to an ADR), you cannot resubmit the claim. Instead, you can request a "56900 reopening" to have the medical documentation reviewed by the Medical Review department. It is not necessary to utilize the Medicare appeals process.
To submit a "56900 reopening", you must complete the CGS Medicare HHH Jurisdiction 15 Redetermination Request Form to CGS. Be sure to note "56900 Reopening Request" in the "Reason/Rationale" field. Submit the form along with the medical documentation to the following address:
J15 - HHH Correspondence
CGS Administrators, LLC
PO Box 20014
Nashville, TN 37202Additional information regarding reopenings is available on the Reopenings page.
Reviewed 09/30/2021
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- If a claim is denied for a clerical error (cert date typed wrong), is it better to appeal, or is it possible to cancel and resubmit?
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Claims denied by medical review cannot be cancelled or resubmitted. In order to receive payment for a claim that was denied by medical review, you must appeal it. Refer to the CGS Appeals/Redeterminations Web page for additional information.
Reviewed 09/30/2021
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- We have already submitted an ADR to CGS using a highlighter to emphasize the important items in the documentation. We were unaware that we should not use highlighters. Will we be automatically denied?
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No, the claim will not be automatically denied. However, due to the imaging of documentation by the Optical Character Recognition (OCR) software, it is possible that the highlighting may obscure the view of the documentation. In the future, we recommend that you use asterisks (*), brackets ([ ]) or underlining to call attention to important information in your documentation. For additional information about preparing your documentation, refer to the Medical Review Additional Development Request (ADR) Process Prepayment Review or the Medical Review Additional Development Request (ADR) Process Postpayment Review Web page.
Reviewed 09/30/2021
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- What if the IDG team is looking at the patient being discharged as no longer suitable, and we get an ADR request on them. Can we submit notes revealing that we are looking at discharge?
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If an ADR is requested, documentation should be submitted. Your documentation should include notes from your IDG meetings, which may include discussion about discharge planning, and the patient's appropriateness for the hospice benefit.
Reviewed 09/30/2021
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- For home health, what are the provider specific edits? For example therapy utilization, length of stay, episodes with 5 or 6 visits, etc.
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Provider specific edits may vary based on the individual agency's issues. This can include therapy utilization, episodes with 5 or 6 visits, or any other issues that appear to be a vulnerability to the Medicare program. CGS does not make listings of provider specific edits available because they are unique to the provider. Instead, a provider on a specific edit will receive a letter explaining their edit.
Reviewed 09/30/2021
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- Is there a place I can go to see the status of all my ADRs or do I have to look each one up by the Medicare Beneficiary Identifier (Medicare ID number)?
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Providers should check for ADRs at least weekly by using the Fiscal Intermediary Standard System (FISS). Providers should use option 12 (Claim Inquiry), enter their NPI number and the status/location 'S B6001'. All claims selected for ADR will appear in a list. FISS will show up to 5 claims per page. Press F6 to scroll down through the list. When your documentation has been received by CGS, the claim is moved from status/location S B6001 to S M50MR for review. Providers can also use option 12, enter their NPI number and the status location S M50MR to display all the claims being reviewed. Additional instructions for using FISS to check for ADRs are available in 'Chapter Three: Inquiry Menu' of the FISS Guide. Resources are also available on the Medical Review Additional Development Request (ADR) Process Prepayment Review. When your documentation has been received by CGS, the claim is moved from status/location S B6001 to S M50MR for review. Providers can monitor the S M50MR status/location in FISS, to verify that their documentation has been received by CGS.
If you have access to the myCGS Portal, prepayment ADRs can be identified by accessing the Medical Review dashboard. For additional information, refer to the myCGS MR Dashboard Enhancements article. If you are not currently using myCGS, register today! Refer to the myCGS Web page for additional information.
Reviewed 09/30/2021
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- What should we do if a hospice claim is denied for length of stay and we have continued to see the patient for an additional 60 days? How much notice must you give the patient before discharging them from hospice care?
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When a hospice determines that a patient is no longer terminal, and all Medicare covered hospice services are going to end, the hospice is required to provide the beneficiary with a Notice of Medicare Non-coverage (NOMNC). This notice must be provided at least two days before all Medicare covered hospice services end; or the second to last day of service (if care is not provided daily). However, your state may have stricter timeframes to which you may need to adhere. For additional information on the NOMNC process, refer to the Hospice Expedited Determination Process Web page.
Reviewed 09/30/2021
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- When a return date is noted as 30 days does that mean that the data must be returned within a 15 day time frame?
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Under the ADR process, initial documentation must be received by CGS within 45 calendar days from the date of the request. If a claim is re-ADRd (the claim appears in S B6001 with reason code 5ADR2), the additional signature documentation must be received by CGS within 20 calendar days of the request. For additional information, refer to the Medical Review Additional Development Request (ADR) Process Prepayment Review or the Medical Review Additional Development Request (ADR) Process Postpayment Review. For situations where a claim is re-ADRd, refer to the CGS "Signature Guidelines for Medical Review " quick resource tool.
Reviewed 09/30/2021
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- The electronic medical record has printed signatures - "signatures on file". Apparently we are required to submit not only a "signature log" but an attestation statement for those signatures - what does the attestation statement need to include?
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At the present time, there is no format requirement or instruction from CMS regarding the attestation statement. An example of the signature attestation statement is included in the Medicare Program Integrity Manual (Pub. 100-08, Chapter 3, §3.3.2.4.C) .
Reviewed 09/30/2021
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- I would like more information on signing up to receive electronic notifications of ADRs. Can you explain that process for me?
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All CGS providers are notified of ADR requests via the Fiscal Intermediary Standard System (FISS). There is no other notification sent to providers. If a provider does not have access to FISS, the provider can complete an EDI Enrollment Packet to request and obtain FISS access. For additional questions about FISS security, contact the CGS EDI Department at 877-299-4500 (Option 2). In addition, ADR documentation may be received by CGS via U.S. Mail, esMD, myCGS or on CD/DVD. For details, refer to the Medical Review Additional Development Request (ADR) Process Prepayment Review Web page.
Reviewed 09/30/2021
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- What is meant by the denial for face-to-face (FTF) is not timely?
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When a home health claim is denied with reason code 5HCO1 (previously -5FFTF), this indicates that the FTF encounter documentation was missing, incomplete or untimely.
For home health, the FTF encounter must occur no earlier than 90 days prior to the start of care (SOC) or within 30 days after the SOC. If the FTF encounter occurred within 90 days of the SOC but is not related to the primary reason for home health, an allowed NPP, facility physician or certifying physician must have a FTF encounter within 30 days after the SOC. For additional information on the home health FTF, refer to the Face-To-Face Encounters for Home Health Certification quick resource tool , the 5HC01: Missing/Incomplete/Untimely Face-to-Face Encounter Denial Fact Sheet and the Home Health Face-to-Face (FTF) Encounter Web page and the Home Health Face-to-Face Encounter online education course accessible from the Online Education Center Web page.
For hospice, the FTF encounter must occur within 30 calendar days prior to the start of the 3rd or later benefit period. For additional information on the hospice FTF, refer to the Hospice Face-To-Face Encounters for Recertification quick resource tool , the 5FFTF: Face-to-Face Encounter Denial Fact Sheet , and the Hospice Face-to-Face (FTF) Encounter Web page.
Reviewed 09/30/2021
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- Please briefly explain Local Coverage Determinations (LCDs).
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LCDs are coverage guidelines developed by CGS, and provide guidance in determining medical necessity of Medicare home health or hospice services. They are part of the Medical Review standards used by CGS staff when reviewing claims. CGS currently has two LCDs.
For home health, the LCD is titled "Physical Therapy - Home Health." For hospice, the LCD is titled "Hospice - Determining Terminal Status". The LCDs for CGS are available on the LCDs/Coverage CGS Web page.
Reviewed 09/30/2021
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- I had recently an ADR for 1 patient covering both July & August. I sent the documentation all together with a cover letter stating it was for both ADR'd periods. Was this OK?
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CGS recommends returning ADR documentation for different claims in separate envelopes, or clearly separating the documentation to ensure that it is not misconstrued as one set of documentation. If you are responding to an ADR request for a July claim, and an August claim, clearly separate the documentation using binder clips or rubber bands, or by mailing in separate envelopes. In addition, providers should attach a screenprint of the Fiscal Intermediary Standard System (FISS) Page 07 to the top of their documentation so that the documentation can be matched to the claim.
Providers can verify that CGS has received their documentation by monitoring their claim using FISS. When documentation is received by CGS, the claim is moved into a status location S M50MR.
As an alternative to mailing medical review (MR) ADR documentation, CGS recommends utilizing the myCGS web portal to submit MR ADR documentation. For detailed instructions, refer to the Forms section of the myCGS User Manual or the myCGS MR ADR Job Aid Web page. If you are not already registered to use myCGS, refer to the Introduction section of the myCGS User Manual.
Reviewed 09/30/2021
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- Is the number of visits in the 'Physical Therapy - Home Health" LCD a recommendation or coverage limitation?
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This is simply a recommendation of the maximum number of visits that would typically be provided. Each visit's documentation must stand alone, showing the level of skill by the therapist, and the medical necessity of this visit and these modalities.
Reviewed 09/30/2021
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- Our agency had an additional development request (ADR). How do we know why the claim was selected? We see an edit reason code 5057T, but don't know what this edit reason code means.
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Providers are able to track the reason why a claim was selected by the reason code that appears on FISS Page 08 of the claim. To access this reason code, select the claim using the Fiscal Intermediary Standard System (FISS) Option 12 by entering your NPI number and the status location (S/LOC) "S B6001". Page 08 has the 5-digit reason code that indicates why the claim was selected. You can look up this reason code by pressing 'F1' to access the Reason Code Inquiry Screen, keying the 5-digit reason code in the REAS CODE field, and pressing "Enter". At the bottom of the ADR narrative (you may need to press F6 to scroll forward through the narrative) is the description of the edit requirements (i.e., why your claim was selected for medical review). See the screenprint below.
Reviewed 09/30/2021
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- If we receive an ADR and know what mistake we have made, is it all right to just not respond to the ADR?
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Always respond to all ADRs even if you know it will be denied.
Reviewed 09/30/2021
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